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Feedback on proposed plan correction of LFS

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XXRyanXXL:
I had an unsuccessful BiMax Surgery last year.
Had no plans on sharing my information but thought it may help other people. So I learned the Surgeon who did my case, just completed his residency, he was training and learning off his mistakes on me. Surgeon did not complete the operation as agreed to, because he doesn't know how, and he tried to make me think his job was excellent and I look great and should NOT pursue any revision, and he claimed to go to conference with other surgeons, where they all suggested I look great and don't undergo any future surgery. This may sound strange to people on this forum, but because the Surgeon lacked the skills to do any rotation, the surgeon tried to give me a jaw line by offsetting the long face appearence he made worse by advancing the lower jaw in the direction of the deformed jaw growth by giving me a massive chin (genio) and moving that forward past my lower lip (2 mm). The Surgeon also sliced the mental nerve, so I have no sensation running to my lower lip, or chin area.
Approximately 5 months AFTER the surgery, the surgeon finally released my VSP, the virtual surgical planning, which I requested I see before I go under the knife. So I had NO idea what he had planned for me. I had long face syndrome (high MP and OP angles), with Class II (10mm overbite). All the surgeon did was elongate my face even more to slide (BSSO) the lower mandible into place.
I am going to be working with other Residents, unfortunately, due to my insurance, so I have to be really cautious on proceeding with another surgery.
My problem is this. I have 3 plans in place from 3 different oral surgeons. They all pretty much converge on this plan.
1. CCW rotation with posterior downgrafting with anterior impaction
2. Upper lip lift (I have long upper lip, and to help with the anterior impaction to show more teeth)
3. Mandibular Inferior Border implants (I have notches below the lower mandible)
4. cheek lift  (cheek pads look descended)
5. Inverted L-osteo
6. mentoplasty (chin reduction)
My MP angle right now is 35 degrees, I was told at BEST, I can achieve a 10 degree improvement, however I want to be in the 23 degree range (normal for my age). I'm afraid of the dreaded "monkey nose" due to the anterior impaction, as this would be impacting my upper jaw into the nasal passage (Alar stich won't help long term). Also according to an article by Wolford on correct OP (occlusional plan) for optimal smile, it stands at 10 degrees, am I correct?
My problem right now, is that when I'm being evaluated by OMS, if a surgeon doesn't have the skill set to perform those operations I listed, they will remain silent and come up with a different plan. I want to stick to this plan though, it makes logical sense to me, and achieves my goals here. I am looking for feedback on this proposed procedure to correct a long face appearence and achieving a sharp jawline (I have no jawline), and some expectations of soft tissue changes I can expect.

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kavan:
I can tell you that the bone displacements in the '3d' proposal to the lower jaw correspond to appox 5 degree angle decrease. Perhaps the proposed implant overlays make up the other 5 degree decrease.

Lefortitude:
its unfortunate you had to trust an inexperienced surgeon due to your insurance.  if i was you, i would save up until i could afford a private surgeon to perform a revision 

ditterbo:
That ramus of yours saved you a few MP angle degrees. Jealous.

kavan:
I'm not clear on a few things. Although, it's clear you would need a lip lift and probabably similar you might need a cheek lift, I'm not clear if insurance pays for that. But perhaps that is neither here nor there.

I'm also not clear whether or not this VSP is a new proposal or the old one

What I'm clear on is that the the VSP photo reflects a 5 degree decrease in the MPA in the direction of CCW (when it's turned to the right). Also, the 'slide UP' to the chin assists in the look of CCW. Although this 'slide' up technically is not an 'absolute' reduction, since it's a displacement of what is already there and nothing is off, the slide up aspect of it is to make the chin look less long from the front. However, whether or not this VSP photo is your PAST one or a NEW proposal, it would be hard to 'see' (in the mirror) the 5 degree decrease simply because the EYE 'wants to see' a 12 degree decrease. I don't actually see an inverted L oesteo on this VSP. So, PERHAPS this was your PRIOR plan.

Now whether or not this VSP was your prior plan or your future plan, the situation is that there is NO amount the maxilla can be CCWed to result in the 12 degree decrease you would need. This is because a significant 'drop down' of the back jaw would be needed and that part WOULD correspond with a 'reverse L' type osteo.

When the doc tells you 'at most' you can get a 10 degree CCW of the mandible with inverted L added to the plan, he's telling you that your MPA EXCEEDS what an inverted L, coupled with a decrease in the OP can do.

That said, there are OTHER cuts that can exceed what a reverse L can do.  Let me know if you would like me to give the link of a (research) paper by docs (in FRANCE) who have a different cut that can give more drop and rotation than the reverse L.

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